Provider Demographics
NPI:1881048528
Name:GREEN, LARON
Entity type:Individual
Prefix:
First Name:LARON
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8912 W TROPHY WAY APT 104
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8912 W TROPHY WAY APT 104
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-2533
Practice Address - Country:US
Practice Address - Phone:901-969-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003292103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst